Marketplace Health Insurance Options for HIV-Positive People

For HIV-positive patients, cost considerations take on added importance because of the expensive antiretroviral prescription medications. As such, assessing premiums alone may not provide an accurate measure of plan affordability for HIV-positive patients.

The Affordable Care Act (ACA) expanded access to health coverage for millions of people, including those with HIV. For HIV-positive patients, cost considerations take on added importance because of the expensive antiretroviral prescription medications that these patients rely on and the importance of comprehensive health coverage to these chronically ill patients.

A new report by the Kaiser Family Foundation, “Marketplace Health Plan Options for People with HIV Under the ACA: An approach to more comprehensive cost assessment,” concluded that assessing premiums alone may not provide an accurate measure of plan affordability for HIV-positive patients because enrollees may find that they face unexpected or higher costs if premiums alone are used to guide plan selection in isolation.

“A more comprehensive assessment of the cost of coverage includes factors beyond just premiums, such as deductibles, drug costs, and out-of-pocket [OOP] maximums,” the report authors Lindsey Dawson and Jennifer Kates stated.

The analysis provides estimates of the costs HIV-positive individuals might expect to face when enrolled in marketplace health plans and describes the characteristics of plans that might offer the greatest value. Costs in 300 different enrollment scenarios are examined, looking at 5 plans in each of 5 sites for 2 enrollee types (one HIV-positive individual with well-managed HIV disease and no other chronic health needs, and one HIV-positive individual with significant HIV care needs) across various incomes. The analysis used 2 measures: expected health costs and total OOP liability.

Key findings include the following:

  • Assessing premiums is not a sufficient way to assess keeping costs low. Plans with the lowest premiums are not necessarily the most cost-effective plan option based on either of the costs measures used in the analysis.
  • Enrollees at the lowest income levels, who have the greatest access to cost-sharing reduction, could find the lowest expected costs in Silver level plans. Thus it may be helpful to look at both plan metal level and enrollee income level. For those with higher income levels, however, the metal tier offering the best value was highly variable.
  • Those at the lowest income level generally paid a greater share of income towards health care costs than those at highest income levels. If enrolled in Silver plans, this could be minimized.

The plan enrollees select has significant consequences for their expected health costs. On average there was a $4054 difference between what they could expect to pay annually if enrolled in the plan with the lowest expected health costs compare with the plan with the highest. There was a $3914 difference in liability between what an enrollee could expect to face annually if enrolled in the plan with the lowest liability compared with the plan with the highest.